Diabetes CME
Editor – Thank you for the excellent CME articles on diabetes (Clin Med December 2014 pp 663–82). It was helpful to read about situations where diabetes might be difficult to manage such as in pregnancy, HIV and rare genetic subtypes of diabetes. Could we highlight another group of patients not discussed in the aforementioned CME articles but who may also have complex diabetes care?
It is increasingly recognised that diabetes care is challenging in the palliative care population. Patients with life-limiting diagnoses and a short prognosis may have diabetes as a comorbidity, and difficult glycaemic control can occur due to the complications of advanced disease.
Achieving acceptable glycaemic control is difficult for a number of reasons. In addition to the altered metabolism seen in cachexia and anorexia, we encounter other concerns in our practice. For example, renal and hepatic impairment may result in hypoglycaemia due to prolongation of action of oral hypoglycaemic agents and insulin. Corticosteroids, used as part of chemotherapy regimens or to palliate symptoms such as fatigue, can cause hyperglycaemia. Finally, medically assisted nutrition via nasogastric or gastrostomy tubes (as seen in patients with motor neurone disease or head and neck cancer) requires careful titration and timing of administration of insulin.
Avoidance of symptomatic hyperglycaemia and hypoglycaemia is important in this population, particularly in the final weeks and days of life. Hyperglycaemia can result in dry mouth, thirst and agitation. Conversely, persistent hypoglycaemia is a potentially treatable cause of deterioration in an otherwise stable patient.
There is debate around what constitutes ‘acceptable glycaemic control’ and how frequently blood sugars should be monitored, especially in actively dying patients. A suggested monitoring regime, as well as practical advice on management related to prognostic groupings is outlined in End of life diabetes care,1 a guidance document commissioned by Diabetes UK. The guidance suggests glucose control targets of between 6–15 mmol/l. However, further work still needs to be done to establish best practice in this challenging and diverse population.
Footnotes
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- © 2015 Royal College of Physicians
References
- 1 .↵
- Diabetes UK
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